In my office hangs an Advertising Council public service ad from the late 60’s/early 70’s entitled “Diagram of a Drug Abuser.” It shows a very sketchy young man with arrows pointing to all the tell tale signs that he’s one of those bad, bad people who do drugs. It was outdated and ridiculous forty years ago and even more so today.

What does a drug addict look like? Well, if you judge a book by its cover – they look like me. They also look like CEOs, soccer moms, and your grandmother. This is especially true when we cross the line between drug dependence and drug addiction.

My wife and I enjoy the USA series, Royal Pains. The show has taken an interesting story line in which the main character (heart throb doctor) becomes addicted to Vicodin following rehabilitation from a major accident and consequent surgeries. His character is noble. He’s the consummate good guy.

It’s not his fault that he became dependent. Long term use of opiates was necessary to prevent him from being in the kind of pain that no human being should have to withstand. If the show told the whole story we might see that his doctors started him on Morphine, stepped down to Oxycontin, down to Percoset, and discharged him with a moderate dose of Vicodin.

Pain is difficult to measure. For all of the gains medical science has made, we’re still using an incredibly subjective 1-10 pain scale. A patient is prescribed what seems reasonable given their injury, and perhaps allotted additional meds for “breakthrough pain.” When we allow patients to determine their own needs with use of opiates; we seem to overlook the connection between emotional pain and physical pain. The truth is that opiates make most people feel a lot better physically and emotionally.

There used to be a line between “drugs” and “medications.” Today they are most often one and the same. The line between dependence and addiction is easy to cross. Dependence is inevitable with repeated use. Anyone who is prescribed opiates, benzodiazepines, or stimulant medications will in a short period of time experience a series of adjustments in which their body and mind come to depend on the substance being present.

Moving from dependence to addiction is more than simply requiring the drugs in one’s system. Addiction can be triggered in dozens of different ways. The key aspect of addiction is that using the drug causes additional problems in one’s life and the drug gradually becomes the focus/most important thing in a person’s life.

For many, their pain continued after their doctors discontinued prescriptions and attaining the pills illegally was sought. For others, supplementing the amount prescribed becomes the catalyst. For still others, the emotional euphoria of opiates is incredibly enticing even in the absence of physical pain.

Nobody intends to become addicted. It’s a Hell that we find ourselves in.

We tend to think of opiates when looking at the line between dependence and addiction but it happens with plenty of other medications as well. For years doctors prescribed “mother’s little helper” (Valium). Today they are more likely to hand out Xanax, Klonopin, and Ativan. These drugs are highly addictive and easily abused. They are very dangerous when combined with alcohol (potentially lethal) and withdrawing rapidly from these medications is incredibly hazardous to one’s health.

For decades now we’ve been handing out Adderall, Ritalin, Concerta and more recently, Vyvanse for Attention Deficit Disorder. Each of these medications is a stimulant and like opiates and benzodiazepines they are a “controlled substance”, meaning that their possession, distribution, and prescription are monitored by the Drug Enforcement Agency (DEA). We’ve known for many years that these drugs are widely abused and wrongly prescribed.

Stimulant medications work on what’s referred to as the “paradoxical affect”, meaning that something can’t work, yet it does. We consider the needs of a person whose minds and/or bodies are moving way too fast and we give them speed. To the person who truly is ADD, stimulants slow them down. To the person who is not ADD, the effects are desirable because these drugs make one feel more alert, energized, and in some cases, euphoric.

Misdiagnosis is the most common cause of crossing from dependence to addiction. The untold story of ADD (we no longer call it ADHD) is that the symptoms of this disorder are also symptoms of a wide spectrum of anxiety disorders. When we don’t ask the right questions; we diagnose the wrong condition and we inadvertently teach people to live their lives at 100mph.

The dependent person crosses a line to become addicted. They most often do this without awareness and their subconscious mind rules these choices. The addict is likely to cross many lines. The addict derives a false sense of security by assuring themselves that there are things they will not allow (injection, harder drugs, having drug use interfere with work or family). This is very similar to the alcoholic who will not allow themselves to drink before 5pm.

The addict finds themselves in a pit of shame and fear. They face judgment from their prescribing physicians/clinicians. They face stigma from countless sources. Their pride and stoicism are obstacles to getting the help they need.

We need to reconceptualize what an addict looks like and recognize that under the right circumstances that none of us are immune.